Admission date may defer from moving date.
PROCESSING FEE:
Mom & Dad’s House charges a one-time processing fee in the amount of $_________to cover resident appraisal, room preparation, arrange and/or review physician’s assessment (cost of actual assessment is incurred by resident), medication set-up, inventory of belongings, cost of admission forms and materials, community maintenance, staff time, dietary provisions, and other admission-related expenses. This fee is collected prior to admission and prior to the required facility assessment and is in addition to, and not a part of, the regular monthly fee.
CONDITIONS FOR PROCESSING FEE REFUND
The facility will refund the processing fee under the following circumstances:
Processing fees will be refunded in full (100%) if the resident does not enter the facility, and the facility did not perform an appraisal (assessment) or failed to provide a written disclosure of the pre–admission fee charges and refund conditions. Mom & Dad’s House will provide proportional refunds of pre–admission fees in excess of $500 during the first three months as described:
In addition to the above provisions, should the facility close, by order of the Department of Social Services or change the use of its function, the above fee is further subject to the following refund schedule:
The resident or the resident's responsible person shall be entitled to a refund of processing fees in excess of five hundred dollars ($500) in accordance with all of the following:
GENERAL PROVISIONS
In this agreement the resident will be referred to as “resident;” whereas resident family members, responsible person or party, and/or conservator will be referred to as “responsible person” or “responsible party.” Facility or licensee, as written in this agreement, is the operator of the facility and referred to as “facility” or “licensee.” Facility may also include employees that render services for and on behalf of facility or licensee.
The following is known as the facility’s Admission Agreement (“agreement” or “contract” or “contract of admission”) and is a valid offer of services. This document and all documents attached or presented at the time of admission are required to be signed at the time of and condition of admission. A signature to this contract represents a mutual acceptance of the provisions contained in this contract and is legally binding upon both parties to perform its portion of the contract. This contract binds both parties to the terms and conditions contained within. Failure of either party to adhere to the terms and conditions may constitute breach of contract. In addition, no rights or duties contained within this contract can be assigned or transferred or delegated to other persons or parties.
A residential care facility for the elderly, licensed by the California Department of Social Services (Department) is not allowed to provide 24-hour skilled nursing care. Mom & Dad’s House does not and cannot provide “one-on-one care.” Mom & Dad’s House does not assign one caregiver to provide 24-hour escort, bedside care, or continuous observation. Under California Health & Safety Code 1569.1, this licensed facility is designed to provide a “humane approach to meeting the housing, social and services needs of older persons,” and to “provide a homelike environment for older persons with a variety of care needs.”
COMPLETE CONTRACT
This document contains the entire agreement and any discussions and/or oral or implied terms which are not included in this contract are excluded and are not considered to be part of this agreement. This is the entire agreement between both parties. Modifications and amendments to this agreement, including any exhibit or appendix, shall be enforceable only if they are in writing and are signed by authorized representatives of both parties.
1. FACILITY / LICENSEE INFORMATION
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Residential Care Facility for the Elderly
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Mom & Dad’s House is a Residential Care Facility for the Elderly (RCFE), licensed by the State of California, Dept. of Social Services, Community Care Licensing. NOTE: A residential care facility for the elderly licensed by the California State Department of Social Services is not allowed to provide 24 hour skilled nursing care.
Licensee:
Licensee Contact:
Phone #
Fax #
Mailing Address:
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2. NON-DISCRIMINATION STATEMENT
Mom & Dad’s House management and staff will not discriminate against a person seeking admission or a resident based on sex, race, color, religion, national origin, marital status, registered domestic partner status, ancestry, actual or perceived sexual orientation, or actual or perceived gender identity.
Gender Identity means a person’s stated identification with a sex, regardless of whether the stated sex is consistent with the person’s physical appearance, surgical history, genitalia, legal sex, sex assigned at birth, or name and sex, as they appear in medical records, and regardless of any statement by any other person, including a family member, conservator, or legal representative, that is contrary. A person who lacks the ability to communicate gender identity retains the gender identity most recently expressed by that person.
Because of recently passed legislation, the facility is compelled to implement record keeping procedures to ensure it ascertains the client’s gender identity, correct name as indicated by the resident, and the use of the correct pronoun (he, she, his, her, etc) when referring to the resident. If resident wishes to decline to provide the information, that is a resident’s right to do so. However, because facility can be cited for not attempting to obtain such information, client is encouraged to provide:
Client’s gender identity _______________________________________
Client’s correct name _______________________________________
Client’s correct pronoun _______________________________________
I choose to exercise my rights and refuse to disclose the above.
3. LGBT RESIDENT RIGHTS (ATTACHMENT # 1)
Mom & Dad’s House – Assisted living facility does not discriminate and does not permit discrimination, including, but not limited to, bullying, abuse, or harassment, on the basis of actual or perceived sexual orientation, gender identity, gender expression, of HIV status, or based on association with another individual on account of that individual’s actual or perceived sexual orientation, gender identity, gender expression, or HIV status. You may file a complaint with the Office of the Sate Long-Term Care Ombudsman 559-224-9106 if you believe that you have experienced this kind of discrimination.
The licensee/administrator is required to advise the resident or responsible person of, and provide a copy of, the as required by Health and Safety Code section 1439.51. Those resident rights are attached.
Resident or Responsible Party, please initial in the space to the left acknowledging that you have received a copy of Health and Safety Code section 1439.51, a copy of LGBT Resident Rights and that these rights have been explained to you. (Attachment # 1)
4. RESIDENT INFORMATION
Resident’s Name: _______________________________________________________
SSN (Voluntary): _______________________________________________________
Birth Date:____________________
Age:_________________________
Admission Date:_________________
Move In Date:____________________
NOTE: "Responsible person" means an individual or individuals, including a resident relative, responsible person or party, and/or conservator, health care surrogate decision maker, or placement agency, who assist the resident in placement or assume varying degrees of responsibility for the resident's well-being.
Resident Language(s) Read
Under a recent revision to the California Code of Regulations, the Department may seek from the facility “the language(s) read by each resident. DSS claims this information will be kept confidential. Please indicate the language(s) read by the resident:
5. RESIDENT REPRESENTATIVE’S INFORMATION:
Resident’s Representative (if not resident) ___________________________________
Relationship ___________________________________________________________
Address ______________________________________________________________
Phone Number _________________________________________________________
6. REFERRAL AGENCIES
This facility may work with public or private referral or resident placement agencies. This facility, if it accepts such a referral and accepts and retains a resident referred by one or more referral agencies, must pay a referral or finder’s fee to such agencies. If you have previously contacted an agency to assist you in finding a residential care facility for placement of the resident, please list here:
__________________________________ Date of initial contact _________________
__________________________________ Date of initial contact _________________
7. PLACEMENT HISTORY
Facility anticipates the ability to meet all of our residents’ needs as identified in the physician’s medical assessment and facility’s initial and ongoing appraisals. Facility asks the resident or resident’s representative to disclose past facility placements or admissions in other residential care facilities and the reason(s) for leaving, as facility wants to ensure this will be the last facility the resident will need. Resident may refuse to disclose this information, but in order to accommodate all resident service needs and to prevent a future move, the facility asks resident or resident’s representative to disclose:
I have not previously been admitted into or placed into residential care.
I have been in other residential care facilities and the reason(s) for moving or relocation is/was _______________________________________________________ ____________________________________________________________________
8. ASSESSMENT AND EVALUATION OF RESIDENT
The facility must, as required by state regulation, conduct a pre-admission appraisal of resident needs and services and the facility’s ability to meet those needs. This appraisal is conducted by the administrator or designee using the criteria found in state regulation sections 87458, 87459, 87461 and 87462. Reappraisals are conducted when there is a significant change in the resident’s condition according to the provisions found in state regulation section 87463, and annually if the resident has a physician diagnosis of dementia. This reappraisal involves the resident’s physician, family and facility staff.
9. FAILURE TO PROVIDE COMPLETE INFORMATION
Facility is required by state law and regulation to conduct a pre-admission appraisal and any needed reappraisal to determine the care to be provided to the resident. Facility and resident, and/or responsible party, must be forthright in providing all needed and necessary information to determine suitability for admission and retention in residential care. Any false or misleading information provided by the resident, responsible party, physician and/or personnel caring for resident, may void this contract, according to state contract law, and lead to relocation or eviction.
10. HEALTH CONDITIONS
This facility does not and cannot provide medical care and is licensed by the Department to meet resident’s need for care. Clients that need emergency or hospital inpatient care or skilled nursing care may not be allowed to return to the facility if the facility assesses a resident and documents the client has a medical need that cannot be cared for within the limits of its license. The facility will advise resident’s physician and responsible party of the inability to meet client needs in addition to seeking placement at a higher level of care, if and until, the resident qualifies for residential care.
11. MEDICAL CARE ASSESSMENTS AND MEDICAL PROVIDERS
Title 22 section 87705(c)(5) requires facility’s residents with a diagnosis of dementia, including Alzheimer’s disease, to have an annual medical assessment to ascertain the ongoing dementia care needs and, conversely, for facility to make needed changes in the resident’s ongoing dementia care and supervision.
It may be necessary for resident to be assessed by a healthcare professional at least once per year and more often if resident has had a significant change in resident’s condition. This is required by Title 22, Division 6, Chapter 8, Section 87705, Care of Persons with Dementia. The Department of Social Services may also require an assessment by a healthcare professional under Title 22, Division 6, Chapter 8, Section 87458. The cost of such assessments are the responsibility of the resident or resident representative.
Facility encourages ALL residents to have at least an annual checkup performed by their current healthcare professional for facility to continue meeting all residents’ needs for care, and for residents to have their current medications and physical needs evaluated to ensure their continuing wellbeing.
12. BLOOD PRESSURE / HEART RATE / WEIGHT MONITORING
If resident requires blood pressure or heart medications based upon vital sign readings resident must provide facility with equipment necessary for staff or resident to take vital sign readings, such as a blood pressure machine. Same parameters apply for weight monitoring.
Facility requests that any equipment furnished for such readings be in good working order. Resident may take own vital sign readings upon verification from resident’s physician of resident ability to do so.
13. DIABETICS
Facility may and can accept diabetic residents. However, facility staff is unable, by state regulation, to administer injectable medications including insulin. Resident’s physician must verify resident can “self-administer” injectable medications, and facility reserves the right to have physician verify resident’s ongoing ability to self-administer injectable medication. Should residents using or needing injectable medication lose the ability to self-administer injectable medication, it constitutes reason for relocation via eviction as facility would not be able to meet the resident’s need. Unless written exception is provided by California Department of Social Services.
14. BASIC SERVICES
To provide a safe and healthful living environment for all residents the following basic services are available. The services actually provided will be those the resident wants and those the resident needs, based on the individual’s pre-admission appraisal, and the needs and services plan. Subsequent resident appraisals may result in the need for additional basic services.
partners, or residents live in the same facility and consent to the arrangement.” In addition, Health and Safety Code 1569.269(a)(17): “To reasonable accommodation of resident preferences concerning room and roommate choices.” Facility will make every attempt to provide a compatible roommate but cannot accommodate all residents with roommates. In this case a private room may be more suitable.
Subsequent resident appraisals may result in the need for additional basic services.
15. RATE FOR BASIC SERVICES AND PAYMENT PROVISIONS
The monthly rate for basic services is $_____ per month.
Resident or authorized representative understands that the stated monthly amount, on a daily pro-rated basis, is due and payable from the Date of Admission, not the Move In Date. In the event that the designated room is not ready for occupancy on this date, the pro-rated amount begins on the date the designated room is ready for occupancy.
The monthly cost is as follows:
TOTAL $
Method of payment accepted:
Payment should be mailed to:
Mom & Dad’s House
12340 Seal Beach Blvd.
Suite B, Box # 401
Seal Beach, CA 90740
Pre-addressed envelopes available at Mom & Dad’s House.
Direct Deposit:
Wells Fargo Bank
Mom & Dad’s House
Account # 1561842566
Routing # 122 000247
The monthly fee is to be paid by ___________________________, on behalf of ________________________________________________.
Please do NOT leave or hand checks with staff.
16. PLANNED ABSENCES AND CONTINUATION OF AGREEMENT
Mom & Dad’s House requires at least a 72-hours notice of resident planned absences to allow facility to prepare medications or other items that may be required. Facility must report to the State resident death; serious injury; an incident that threatens the welfare, safety or health of the resident; or an unexplained absence of the resident. Please immediately report to Mom & Dad's House if any of the above occurs while resident is in the custody of family.
If the resident is away from the facility for hospitalization, vacation, temporary placement outside this facility, etc., the monthly rate continues. The facility will hold the room up to the last day of a paid month unless the facility is notified in writing of the resident’s discharge. Individuals other than the resident must have the legal right to discharge as determined by the facility upon seeing legal documentation.
If the resident does not return to the room after being away and by the next monthly fee due date, the facility will hold the room for seven days upon receipt of a week’s fee prorated on a daily basis. For each additional seven-day period, another week’s fee must be received. Failure to pay this fee by the due date may result in involuntary discharge from the facility. Title 22 section 87224 requires a 30-day notice of eviction for non-payment of fees.
17. RELEASE OF LIABILITY WHEN IN FAMILY CUSTODY
By signing this agreement, I absolve Mom & Dad's House of any liability that occurs when the resident is away from Mom & Dad's House for a visit, outing, doctor’s or similar medical appointment, day care, vacation, or similar event which requires the resident to be in the custody or care of someone other than facility staff.
18. FUNDING SOURCE
The resident has the right to refuse to disclose the monthly fee-funding source. To decline to disclose this information simply write, “refuse to disclose” in the blank below. My funding source for payment of the monthly fees is________________________ ____________________________________________________________.
The resident funding source:
Include SSI/SSP funds. (Voluntary Disclosure)
Does not include SSI/SSP funds. (Voluntary Disclosure)
Mom & Dad’s House does not accept SSI/SSP dependent residents, and cannot accept SSI/SSP beneficiary’s personal and incidental needs allowance to pay for basic services, including care and supervision. Facility does not accept voluntary contributions from others as payment. Failure to reveal to the facility the SSI status of the resident may void this contract.
19. RATE CHANGE
_____ Any change in basic rate or optional services will be preceded by in writing 90 (ninety) days notice stating the amount of the increase, the reason for the increase, and a general description of the additional costs. This does not apply to a rate increase due to change in level of care or condition change which may be implemented after providing a twobusiness day written notice, nor does it apply to optional services provided under a separate fee for service management with the resident.
_____ Written notice will be provided to the resident and responsible person, if any, within two business days of providing service at a new level of care that results in a rate increase. The notice will include a detailed explanation of the additional services provided at the new level of care. Any change in the residents condition is documented by facility and physician's assessment.
_____ Hospice/Palliative care is provided at Mom & Dad’s House when prescribed by a physician and requested by resident or responsible person. An additional charge of $______ per month on top of his/her monthly rate will be assessed by the facility when hospice/ palliative care is provided. This charge is separate from the charges of the Hospice /Palliative Agency, which are usually paid by Medicare.
20. ANNUAL DISCLOSURE OF AVERAGE MONTHLY RATE INCREASES
_____ Mom & Dad’s House average monthly rate increase, and the average percentage of increase for each of the previous 3 years is explained in chart below. This disclosure is updated by January 31 of each year.
Please expect a yearly rate increase on the anniversary of admission.
|
YEAR |
AVG MONTHLY RATE INCREASE |
PERCENTAGE |
21. OPTIONAL SERVICES
Optional Services are those services provided by Mom & Dad’s House that are not included under basic services and have additional fees.
_____ Special Food Products - Special food items are those food items not ordinarily used by Mom & Dad's House and are purchased for an individual resident's use and consumption at the request of the resident. If requested, special food products purchased for an individual resident will be itemized on a monthly statement and charged at facility's cost [as allowed by Title 22 section 87464(e)(3)].
_____ Field Trips - Mom & Dad’s House has incorporated various field
trips into our activity schedule, to ensure that our residents are
engaged physically and mentally, and have a change of scenario once in
a while that helps them cut the routine. These field trips vary from
visits to the Senior Center for exercises, lunch, bingo, parties,
movies, mall, church, city events like luncheons, etc. To be able to
make these field trips happen, we need to staff properly, and plan
ahead to coordinate all logistics. Mom & Dad’s House charges $______
per person per field trip, to cover the costs inherent to make these
field trips happen. This charge is added into the monthly
statement.
The field trips are voluntary, and because of the risks when taking
our residents out of our home are higher, we require a signed waiver
(Attachment # 2) to be able to take your loved one in our field trips,
and acceptance in writing to take your loved one in field trips, and
how many field trips do you approve per month.
If accepted, the number of field trips per month is _____.
____ Long Distance Phone Charges—If resident uses facility phone to make long distance phone calls, these calls are charged to the resident at the cost of the call. A copy of charges will be placed in the resident’s file and itemized on a monthly statement. Resident may install a private line in resident living area at resident expense. Resident or resident’s representative must pay all charges associated with installation and maintenance of the phone and phone line and pay all charges for usage.
22. THIRD PARTY SERVICES
Third party services are those not operated, provided or controlled by the Mom & Dad’s House . The fees will vary depending upon provider. The resident or responsible person will enter into a contract directly with the third party services provider. Third-party services include, but are not limited to:
|
ITEM AND SERVICE |
TIME AND FREQUENCY |
RATE |
|
Doctor and Podiatrist |
As needed or requested |
As agreed between resident and provider |
|
Home Health Nurse |
As needed or requested |
As agreed between resident and provider |
|
Hairdresser/Cosmetology Services |
As needed or requested |
As agreed between resident and provider |
|
Pharmacy Services |
As needed or requested |
As agreed between resident and provider |
|
Incontinent care products (Briefs, Bed Pads, Gloves, Wipes) |
As needed or requested |
As agreed between resident and provider |
|
Private Companion |
As needed or requested |
As agreed between resident and provider |
These services may be arranged by Mom & Dad's House when requested by the resident or responsible person. Facility reserves the right to monitor and assess the quality of these services. Rates for third party services may increase without notice, and facility is not responsible for advising resident or responsible person of increases. Some third-party providers, if hired by the resident or responsible person, will be subject to the conditions listed under "Private Companion.”
23. PRIVATE COMPANION
24. HOUSE RULES / FACILITY POLICIES:
This Admission Agreement provides the resident and responsible person with a detailed list of house rules provided at the time of admission.
The following rules must be observed. Failure to comply, will be grounds for eviction.
When a resident is first placed in the facility it is particularly important that they be giving time to adjust without interference, let them know the day(s) and time you will be coming to visit.
The facility hereby believes these house rules/general policies are reasonable and necessary. The resident has the right under California State Health and Safety Code 1569.885 to suggest changes to these policies.
25. PROCEDURE FOR SUGGESTING HOUSE RULE CHANGES
Facility rules may be changed upon suggestions from the resident. AlI resident suggestions must be in writing and presented to the Administrator. The Administrator will review written suggestions within five working days of receipt. In considering policy changes Administrator will present suggested changes to the resident council (if one has been established) to ensure no resident right is violated or resident safety is compromised if a change occurs. After the review of written suggestions, Administrator will render a decision in writing to the person who submitted the suggestion.
26. FACILITY VISITING POLICY:
Mom & Dad's House encourages regular visits from family, friends and clergy.
Mom & Dad’s House - Assisted living facility will ensure that all communications to the facility from family and responsible persons answered promptly and appropriately. We will encourage regular family involvement with the resident and shall provide ample opportunities for family participation at the facility. Visitors, including ombudspersons and advocacy representatives, are permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
Resident shall have reasonable access to telephones, to both make and receive confidential calls. The facility does require reimbursement for long distance calls. Resident will also be able to mail and receive unopened correspondence in a prompt manner.
27. GRIEVANCES / COMPLAINTS:
At Mom & Dad’s House we want to be sure that you are satisfied with the care that you receive from us. Please let us know right away if there is a problem or concern about any aspect of our service.
As a Mom & Dad’s House resident you have the right to file a grievance about anything you are not satisfied with regarding our service.
Here are a few examples:
If you file a grievance, you will continue to receive services the same as before you filed the grievance. Mom & Dad's House employees will not discuss your grievance with other participants or anyone else not involved with investigating your grievance.
You may file a grievance with the administrator at (949) 381 - 1792, either verbally or in writing, at any time regarding facility’s general policies. The Administrator will review the grievance within five working days of its receipt with the resident council (if facility has one) and render a decision to the individual filing the grievance. We will continue to furnish you with all services at the frequency provided in the current plan of care during the grievance process.
It is the responsibility of the administrator to investigate and seek a resolution of the grievance, as soon as possible. All efforts will be made by the team to pursue a resolution to its outmost ability, so that problems with service delivery do not go unresolved. If you or your family member is still not satisfied with the resolution proposed by the team, you will be informed, either orally or in writing, of what action you may take.
The resident or resident’s representative has the right to file a grievance with Community Care Licensing or the State Ombudsman, or both, to resolve any complaints regarding facility practices. The ombudsman is intended as a resource for both of the following accessing additional information regarding resident care at the facility and for reporting resident care complaints. The following information is also contained on the resident’s (personal) rights form.
Under Health and Safety Code 1569.885, the following information is required in this admission agreement:
The resident has the right to present grievances and recommend changes in policies, procedures, and services to the staff of the facility, the facility’s management and governing authority, and to any other person without restraint, coercion, discrimination, reprisal, or other retaliatory actions. The licensee will take prompt actions to respond to residents’ grievances.
No officer or employee of Mom & Dad’s House by law (AB581), will discriminate or retaliate in any manner, including, but not limited to, eviction or threat of eviction, against any person receiving the services of the licensee’s residential care facility for the elderly, or against any employee of the licensee’s facility, on the basis, or for the reason that, the person or employee or any other person has initiated or participated in the filing of a complaint, grievance, or a request for inspection with the department pursuant to this chapter, or has initiated or participated in the filing of a complaint, grievance, or request for investigation with the appropriate local ombudsman, or with the state ombudsman.
28. ABUSE REPORTING
The personal rights form provided to the resident and the resident’s representative provides information about procedures for reporting known or suspected elder abuse, including the tollfree telephone number of the State Long-Term Care Ombudsman's CRISISline and the telephone number of the nearest approved organization for long-term care ombudsperson activities.
29. LICENSING REPORTS
Licensing reports are available for review at Mom & Dad's House, and copies of licensing reports and other documents pertaining to Mom & Dad's House are available from the district office of the Department of Social Services.
30. DEPARTMENT OF SOCIAL SERVICES RIGHTS TO ACCESS RECORDS:
The facility must allow the Department to review resident records kept by the facility. However, under H&S Code 1569.269(a)(3) resident must consent to the release of personal and private information and may legally refuse this inspection. Please indicate which resident right will be exercised. Either consent may be withdrawn at any time in writing by resident or resident’s representative.
I authorize the Department to inspect my personal records kept by the facility.
I do not authorize the Department to inspect my personal records kept by the facility.
31. LEGAL DOCUMENTATION
Mom & Dad's House must have copies of all legal documents, which allow someone other than the resident to make decisions regarding health and finances. These documents include, but are not limited to, Durable Powers of Attorney for Health Care, and Financial.
32. RESIDENT PERSONAL RIGHTS:
Any person admitted to the facility must be advised of his/her personal rights specified by law.
The resident and the resident’s representative, if any, is entitled under California State law to receive a copy of the resident’s personal rights pertaining to admission and retention in this facility. Under Health and Safety Code 1569.889, the personal rights form must contain the Ombudsman’s phone number. The form, produced by the Department, is LIC613C-2, and is provided to residents and responsible parties at the time of admission. I have received a copy. Under Title 22, Division 6, Chapter 8, Section 87468.2(f), the Department of Social Services does not have the authority to waive the personal rights in this regulation section.
33. HOSPICE / PALLIATIVE AND HOME HEALTH
If resident is recommended by a physician to be placed on hospice for a terminal illness as certified by two physicians, Mom & Dad’s House will adhere to Title 22 sections 87632 and 87633 and ask resident and/or responsible person to submit a written request to facility to be placed on hospice while residing in the facility. Mom & Dad’s House must approve the written request for retention and approve all hospice care plans prior to the initiation of hospice services by an outside agency. Mom & Dad’s House has worked with many hospice agencies in the community and may refer or recommend resident to agencies trusted by Mom & Dad’s House. Mom & Dad’s House reserves the right to reject the hospice agency selected by the resident or responsible party if facility has had trouble with that agency in the past. Mom & Dad’s House requires resident and/or responsible party to inform facility when client may be placed on hospice, so all the requirements of the state can be met, and facility may evaluate the services hospice agency claims to provide. If services and communications from agency are not to the level expected by Mom & Dad’s House, facility has the right to request change of provider.
Consent for Hospice Care and Facility Retention
Should I require hospice services, this agreement hereby acts as my request to receive hospice care and to be retained in the facility while receiving such care. I understand the facility may be required to deny this request if my condition has progressed to a condition not allowed in a residential care facility [Title 22, Section 87724(i)], if the facility’s hospice waiver capacity is at a maximum, or if roommate, if any, withdraws consent to any shared living space [Title 22, Section 87633(h)(5)(A)].
Roommate Consent for Hospice
Should resident occupy a shared room and the roommate requires hospice care, by signing below, resident consents to allow hospice into the shared living space. This consent may be withdrawn verbally or in writing by resident and/or resident’s responsible party.
Sharing of Resident Information—Home Health and Hospice
Should resident require any health care services provided by a home health or hospice agency, resident hereby agrees to release all written information provided by the home health or hospice agency to the facility to ensure that the resident’s care needs can be met by the facility, and to prevent any prohibited conditions from developing.
34. PERSONAL PROPERTY / THEFT AND LOSS PROGRAM: (ATTACHMENT # 3)
_______ I have received a copy of LIC 621 Personal Property/Valuables Entrusted to Facility.
Resident or Responsible Party, please initial in the space to the left acknowledging that you have received a copy of Health and Safety Code Sections 1569.74, 1569.152, 1569.153, 1569.154. and Title 22 Section 87218 and an explanation and a copy of the facilities Personal Property Theft & Loss Program. Resident or Responsible Party, please initial in the appropriate space below:
_________ I agree to have my clothing inventoried per the facility theft & loss policy.
_________ I opt NOT to have my clothing inventoried.
However, California Health and Safety Code 1569. 153(d) and Title 22 Section 87218(a) (1) mandates that other personal property items be inventoried at the time of admission and as brought into the facility after admission.
All items must be requested in writing to be added to or deleted from the Personal Property Inventory List, as mandated by California State Health and Safety Code 1569.153(d). Responsible person is asked to assist facility in marking all resident items for identification purposes.
I have received a copy of this policy and procedure, which includes California State Health and Safety Codes 1569.152 - .154. . (Attachment # 3)
35. BREAKAGE / DAMAGE FEE
The facility is not allowed to collect a deposit against possible damages caused by the resident. There is no prohibition in Title 22 or Health and Safety Code for charging the resident or responsible person for damages that may be caused by the resident. This includes breakage of facility property, blocking of toilets or plumbing by placing inappropriate items into plumbing fixtures (i.e. clothing, adult briefs, etc.), and the soiling of facility carpeting. The facility will not attempt to collect a fee for normal wear and tear caused by the resident, and any suspected damage or breakage will be discussed with resident or responsible person. Any amount billed for damages will be the actual cost of replacement or repair.
36. RENTER’S INSURANCE
Mom & Dad’s House does NOT charge rent or refer to its service fees as “rent.” This facility is NOT governed by Fair Employment and Housing. California Health and Safety Code 1569.147 states facilities are not under any form of rent control.
However, Mom & Dad’s House strongly recommends that resident obtain renter’s insurance that can be obtained through most insurance companies. Renter’s insurance protects resident’s clothes, electronics, furniture, prosthetic devices, etc., should these be lost or damaged, or even stolen. Facility’s insurance does not cover resident’s personal belongings.
37. HOARDING
Hoarding is defined as “the persistent difficulty discarding or parting with possessions, regardless of their actual value.” Mom & Dad’s House has specific fire clearance requirements and is unable to allow residents to “hoard” items that may block exits and passageways, or to take up space used for necessary personal items. Resident is not allowed to hoard disposable items such as newspapers, magazines, shopping bags or anything else determined by the facility administrator or staff to be a fire, tripping or other hazard. Mom & Dad’s House does not “store” resident items that are not related to resident personal care or necessary for resident physical needs. Facility will discuss this issue with resident and/or representative.
38. TELEPHONE SERVICES
A central telephone is available for all residents. Local calls may be made at no charge. Long distance calls will be billed to the resident monthly at the actual cost of the call as outlined on the telephone bill.
The licensee/administrator is required to advise the resident or responsible person of, and provide a copy of a Telecommunication Device Form (LIC 9158) for each resident
whose pre-admission appraisal or medical assessment indicates he/she is deaf, hearing-impaired, or otherwise disabled.
I have received the Tele-communications Device Notification Form.
39. ADVANCE HEALTH CARE DIRECTIVE:
I have received a copy of the State’s brochure:
“Your Right to Make Decisions About Medical Treatment.” (Attachment #
4)
Mom & Dad's House must provide the resident or responsible person with the information contained in Title 22 section 87575.1(b) and (c), which is hereby presented:
Facility advises resident and representative to have a completed Do-Not-Resuscitate (DNR) or Physician Orders for Life-Sustaining Treatment (POLST) on file with facility and obtained prior to or within two weeks of admission.
To comply with state regulations, the facility must provide the resident or resident’s representative with the following information contained in Title 22 section 87469 (b), (c), and (d):
87469(b): Residents shall be permitted to have a Request Regarding Resuscitative Measures form on file, which can include Physician Orders for Life Sustaining Treatment (POLST) and/or a Do-Not-Resuscitate (DNR) Form in their facility file.
87469(c): If a resident who has a Request to Forego Resuscitative Measures, and/or an Advance Health Care Directive and/or a DNR form on file experiences a medical emergency, facility staff shall do one of the following:
OR
vocational nurse if the physician or nurse is in the resident’s presence at the time of the emergency and assumes responsibility.
87469(d) After following the procedure in Section 87469(c)(1), (2), (3), or (4), as outlined above, facility staff shall notify the resident's hospice agency and Health Care Surrogate Decision Maker, if applicable.
40. INFORMING EMERGENCY RESPONDERS
By state laws and regulations, the facility cannot make any other arrangements regarding the calling of 911 in case of resident emergency. If the resident is receiving hospice services from a licensed hospice agency, facility is allowed under Health and Safety Code 1569.73(c) to call the hospice first, not 911, if the resident experiences a life-threatening emergency related to the resident’s terminal illness.
Facility does not have a policy prohibiting any employee from voluntarily providing emergency medical services, including, but not limited to, CPR, in response to a medical emergency unless resident has expressed, in writing, a request regarding resuscitation, DNR or POLST form. In addition, facility may adopt or enforce a policy authorizing any employee trained in emergency services to provide those services to facility residents. Notwithstanding the above, any available facility employee may voluntarily provide emergency medical services if a trained and authorized employee is not immediately available or is otherwise unable or unwilling to provide emergency medical services.
41. CONSENT AND EMERGENCY ROOM (ER)
If resident is transported to the emergency room by ambulance or other means for an incident or 9-1-1 call, Mom & Dad’s House staff will provide the ER staff with resident’s personal information, insurance, POLST and/or DNR, and health condition (physician’s Report). Upon consent, facility will provide some information for emergency responders (see “consent” in this agreement). Facility is unable to go with the resident to the ER and sit and wait with the resident, and facility is unable to transport resident back to the facility. Responsible party is charged with arranging with the facility or others to return
the resident safely back to the facility, which may include non-medical transport companies. Facility will work with the family and the resident to insure a safe return. When a resident is transported to the ER, this represents a “transfer of care,” and the facility is not liable for any incidents that may occur to the resident at the time the client is transported away from the facility. Facility cannot provide an escort.
The signature(s) below give consent to the facility to release to emergency response personnel the following documents:
All other resident records are confidential and are not released to any party or agency without the express written consent of resident or responsible person.
42. EMERGENCIES / NATURAL DISASTERS
In case of an emergency where we have to evacuate Mom & Dad’s House on short notice, we require an Emergency Backpack for each resident. This backpack should be large enough to hold the main items required, but light enough that our ambulatory residents can carry it themselves and non-ambulatory can carry in their lap while in their wheel chair. This backpack should be labeled and provided to staff within the first week of admission.
Facility is prepared for but hopes that it will not be affected by a natural or man-made disaster. Facility cannot control the occurrences of earthquakes, floods, fires or other natural or manmade disasters (including terrorist incidents). Should a disaster occur, facility will implement its emergency disaster plan filed with the Department at the time of licensure. Such a plan is available to residents and their responsible parties. Facility cannot guarantee emergency authorities can reach facility or that facility has any priority with emergency agencies in the event of any disaster or emergency. Facility’s off-duty staff may not be able to reach the facility in case of an emergency or may be compelled to attend to their own family’s needs. Facility’s on-duty staff may also have to attend to family needs and may attempt to leave the facility. However, licensee will ensure all residents’ needs are met and supervision will be present 24- hours-per-day.
In addition, facility cannot guarantee it can evacuate the clients if roads, emergency authorities or other conditions prevent it. Facility will make every attempt to comply with Health and Safety Code 1569.695 in contacting emergency agencies, families,
hospice agencies (if necessary) and others to assist in evacuation should it become necessary to vacate its premises. Facility is required to be self-reliant for at least 72 hours but may not be able to sustain its operation if premises become uninhabitable or evacuation is ordered by emergency agencies.
Facility will seek the assistance of resident’s responsible party to assist in relocating and/or transporting the resident to temporary housing. Again, it is hoped that no emergency or disaster would necessitate evacuation, but recent events in our nation and around the world make it necessary to be prepared for any known disasters. Facility may and will seek the help of resident’s responsible parties to ensure the health and safety of the client in the event of an emergency.
Under Health and Safety Code 1569.695, revised for 2019 by the California State Legislature, facility is required to make every attempt and effort to communicate with resident’s representative during any emergency. Please provide facility with the best possible way(s) to reach resident’s representative during an emergency or disaster. This may include landline, cellphone, email, social media, text messaging, etc.:
_____________________________________________________________________
Out of state contact in case of an emergency:
_____________________________________________________________________
43. PERSONAL PROTECTIVE EQUIPMENT (PPE)
This facility is required to practice basic universal precautions as defined in Title 22 section 87101(u). This includes handwashing with soap and water, the wearing of non-sterile gloves, proper disposal of infectious materials and the cleaning with a bleach-based disinfectant. However, if ordered by the Center for Disease Control, World Health Organization, California Department of Public Health, Department of Social Services or other authoritative health organizations, facility may be forced to take more drastic measures to prevent the transmission of highly infectious diseases, i.e., COVID-19, HIV, SARS, flu of all types, H1N1, etc. Then, facility may have to invest in specialty personal protective equipment that is not part of its basic universal precautions’ protocols.
These can and may include the purchase of N95 facemasks (or similar), gowns, foot coverings or booties, high-alcohol hand sanitizers, and other items. Facility must pass on these added costs to residents and visitors and will do so at its cost. These will be itemized on resident statements.
44. DEMENTIA CARE:
Mom & Dad’s House provides environments, services and programs specific for dementia care and they are described in the facility’s Plan of Operation. Plan of Operation is available for review upon request. The facility does NOT have secured perimeters, thus Title 22 sections 87705(k)(l) do not apply.
45. MEDICATIONS:
If resident’s representative does not purchase physician-prescribed medication for facility to assist in medication administration, facility is not responsible for obtaining or paying for resident medication as allowed and mandated under California and United States contract law provisions known as the Statute of Frauds. Facility is required by law to report the failure to provide medication to the physician, law enforcement, Adult Protective Services, the Ombudsman, and the Department of Social Services. The failure of a resident’s representative to provide medication may be prosecuted as elder abuse, a criminal offense in California. Facility is not legally required to obtain the medication as this would be in violation of Title 22 “Health Care Surrogate Decision Maker” provisions.
Title 22 regulation # 87465 requires that all prescription and nonprescription medications for which Mom & Dad’s House provides assistance must have a pharmacy label on the medication, as well as a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, containing the following information:
Should resident require medications to be crushed or altered (i.e., cutting), by signing below, resident or responsible party consents to allow facility to place medication(s) into food or other substances—called “hiding or camouflaging” by state regulation—to enhance taste or allow ease of swallowing. Facility may consult with pharmacy or resident physician to ensure that resident medications may be safely crushed or altered. This consent is required under Title 22, section 87465.
Upon death of a resident, Mom & Dad’s House will destroy all medications belonging to the deceased resident. No medication will be given to the POA, relative or friend.
Mom & Dad’s House does not allow the use of medical marijuana delivered via cigarette or other method of smoking or inhaling. Other forms of marijuana delivery may be allowed and must be discussed with the licensee prior to admission or prior to its usage. The facility does not allow the cultivation or growing of marijuana in the facility. Medical Marijuana will be treated by the facility like any other medication.
46. USE OF PHARMACY OUTSIDE FACILITY’S UNIFORM PACKAGING SYSTEM, E-MAR & COMMUNICATION SYSTEM
Under California law a facility cannot require a resident “to purchase medications from any particular pharmacy.” However, this same law allows a facility to establish reasonable policies and procedures that are necessary to assist residents with the taking of their medications. The facility’s uniform packaging system, also known as “bubble packing,” and pre-packed system is a convenient and safer mechanism for the facility to manage a resident’s medications. It involves specialized packaging used by pharmacies to reduce medication errors and insures a reasonable assistance and assists facility in staying in compliance with state and federal laws and regulations.
Mom & Dad’s House preferred pharmacy also has an electronic medication management system that seamlessly integrates prescriptions and facilitates administration of medications.
If resident does not wish to use Mom & Dad’s House preferred pharmacy, the facility reserves the right to charge resident $______ per month. This charge is necessary as the facility must dedicate more time and efforts to safeguard medications, order medications, contact pharmacies, count medications, handwrite centrally stored sheets as required by the state, etc. Signing below acknowledges this extra charge IF the resident or responsible party opts out of facility’s Uniform Packaging System. This includes medications provided to the resident while in hospice care. Exceptions may apply for Care Packs or medications that preferred pharmacy may not provide in a timely manner.
47. CONDITIONS FOR EVICTION:
1. Three-day Eviction Notice
Mom & Dad’s House may give a 3-day written notice to evict, provided written approval is obtained from the Department of Social Services. The Department may grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior that is a threat to the mental and/or physical health or safety of himself or to the mental and/or physical health or safety of others in Mom & Dad's House. Copies of any notice of eviction will be sent to the resident, responsible person, Community Care Licensing and any placement agency.
California law requires specific information to be included within the notice of eviction (notice to quit), and facility will comply with all legal requirements.
In case of an eviction, the eviction notice will include the following information as required in SB 781:
2. Sixty-day Eviction Notice
Mom & Dad’s House may evict the resident for one or more of the following reasons:
Mom & Dad’s House will provide at least a 60-days written notice to resident, resident’s representative, and Community Care Licensing of the facility’s intent to evict.
3. Facility Responsibilities under Forfeiture of License or Change in Use of Facility
If the above, 60-day eviction does occur facility will take all reasonable steps to transfer affected residents safely and to minimize possible transfer trauma, and shall, at a minimum, do all of the following:
Facility Responsibilities under Closure or Change of Use.
The facility is responsible for the following should eviction take place under closure or change of use provisions:
those agencies to locate alternative placement sites, contact relatives or other persons responsible for the care of these residents, provide onsite evaluation of the residents, and assist in the transfer of residents.
48. FAILURE TO PAY
Facility reserves all rights to collect any unpaid balances using all possible means. The resident or responsible person may be liable for all reasonable legal fees and costs of collection. Failure to pay also constitutes a breach of contract, and facility may seek in a court of equity payment under the terms of this contract.
49. RELOCATION AND APPEAL NOTICE:
No involuntary transfer, discharge, or eviction will take place without proper notice. In case of relocation ordered by DSS, residents may appeal the decision directly to Community Care Licensing. In case of discharge or eviction, resident may appeal first to the Administrator/ Licensee and if the resolution of the complaint is not acceptable, address the complaint to Community Care Licensing.
Mom & Dad’s House is offering relocation assistance by providing the resident and/or responsible person with a list of other facilities or placement agencies. H&S Code Section 1569.316 and 1569.47 discourage a facility from making a direct referral to another facility. It is the resident or responsible person’s responsibility to ensure the new facility can care for the resident within the confines of its license.
NOTE: When DSS orders relocation of a resident, due to a health condition that cannot be cared for within the limits of the licensee, the resident shall not be held responsible for meeting any advance notice requirement imposed by the licensee in the admission agreement. The licensee shall refund any money the resident would have been entitled had notice been given as required by the admission agreement.
Department Relocation
If a resident has a health condition which cannot be cared for within the limits of the license, requires inpatient care in a healthy facility, or has a health condition prohibited by Title 22 Sections 87582(c) or 87701, the Department may/shall order the licensee to
relocate the resident. In cases where the Department determines that the resident is in imminent danger because of a health condition(s) which cannot be cared for in Mom & Dad's House or which requires inpatient care in a licensed health facility, the department shall order the licensee to immediately relocate the resident.
50. REFUND POLICY
_____ The monthly fee paid in any given month will not be refunded in case of a temporary leave or in case of voluntary permanent departure, unless a written 30 days notice is given to the administrator, in that particular month, regardless of the reason.
_____ The total monthly rate set forth in the admission agreement will not be prorated on a daily basis upon the resident’s permanent departure from the facility during the month.
A prorated refund will be made, if requested, only in these specific instances:
1. In case of death of the resident.
51. FIREARMS
To ensure the safety of residents and staff firearms and ammunition are not permitted within any part of Mom & Dad’s House.
Prior to admission, residents will be informed of the prohibition of any firearm or ammunition within any part of the community.
On admission the resident and or responsible party, as appropriate will be asked if any firearms are being brought into the building.
Should a staff member suspect or identify a firearm or ammunition is present in the community, the administrator is to be notified immediately.
If the resident refuses to allow the firearm to be removed or at anytime staff or resident safety is in danger, the police or sheriff will be notified immediately by calling 9-1-1.
52. CONSENT TO PHOTOGRAPH
By initialing below, I hereby authorize this facility to use my image (photo) for identification purposes only to ensure resident safety and well-being. This may include photographing portions of resident’s body to document skin condition. Any photos of this nature will be kept in strictest confidence and not used commercially. Initials _____.
In addition, I hereby authorize Mom & Dad's House to use resident’s image (photo) for possible use in public forms of advertising including but not limited to website, brochures or local advertising. Initials _____ .
53. BEDRAILS AND HOSPITAL BEDS
The Department allows the use of bedrails but under very strict conditions. Thus, the facility must approve all beds equipped with bedrails prior to occupancy, especially “hospital beds,” to ensure compliance with state laws and regulations and facility policies. The State allows “half bedrails,” but only to assist the resident with mobility, i.e. turning, repositioning and transferring. Under state regulations, bedrails require a physician’s order specifically stating for use with mobility and the bedrails must be as close to the head of the bed as possible. Facility requires half rails be no less than 2-3 inches from the head of the bed. Full rails are not allowed unless the resident is admitted onto hospice.
Mom & Dad’s House requires hospital beds provided by hospice companies to be fully electric, to protect staff from back injuries from lifting the bed up and down manually. Hospital beds supplied by hospice companies should be approved by facility.
54. FALLS
There are many factors that can contribute to falls – medication, poor eyesight, illness, poor oxygenation, footwear, resident mobility, aging, etc. Many residents are admitted to residential care homes because of fall risk. Mom & Dad's House provides a high level of care but is unable to provide one-on-one attention. Even under higher supervision residents are at risk of falling. Facility asks that resident rooms not be furnished with throw rugs or extension cords, and any oxygen tubing kept to a manageable length.
55. HIRING MOM & DAD’S HOUSE FOR PERSONAL CARE OUTSIDE MOM & DAD’S FACILITY
Client agrees not to recruit, contract with, or employ any of Mom & Dad's House’s employees, agents, contractors, or subcontractors that provide Services to our residents during the term of the Agreement and for a period of 12 months after the termination of this Agreement. Client agrees that the restrictive covenants contained in this paragraph are fair, reasonable, and necessary for the protection of the legitimate business interests of Mom & Dad's House. The provisions and terms of this Paragraph shall survive the termination of this Agreement. Should the Client recruit a Mom & Dad's House employee, agent, contractor, subcontractor, or subcontractor, Client shall pay Mom & Dad's House $___________.
56. TIPPING OF STAFF AND LOANS
It is Mom & Dad's House’s policy that members of its staff not receive or solicit tips from the residents or individuals visiting the resident, including family members. Please do not give money to the staff, unless cleared by the administrator.
The facility does not allow resident and/or responsible party to loan money to staff or the licensee. Loans create numerous legal entanglements and paperwork for the licensee. It is clearly the policy of the facility to NOT allow loans to be given to anyone affiliate with the facility, especially care staff.
57. MISSING RESIDENTS
Under California Health & Safety Code 1569.317, every residential care facility for the elderly shall develop and comply with an absentee notification plan to address issues that arise when a resident is missing from the facility.
Mom & Dad’s House developed and complies with an absentee notification plan for each client or resident to address issues that arise when a client or resident is missing from the facility. This plan is part of the resident’s written record of care.
If a resident is missing from the facility, the administrator of the facility, or his/ her designee, will do the following:
58. END OF LIFE OPTION ACT
Facility has elected, for reasons of conscience, morality or ethics, to not have its employees participate in activities related to the “end-of-life” act. This includes delivering the prescription for, dispensing, or delivering the prescribed aid-in-dying drug; and being present when the resident takes the aid-in-dying drug prescribed by resident’s attending physician. Any decision made by the qualified individual to obtain and/or take aid-in-dying medication will NOT result in resident eviction or threat of eviction, discrimination, or harassment. Facility will NOT place aidin- dying medication in its centrally stored medication location, and if resident stores the medication in his or her room, resident’s physician must indicate the client is capable of selfstorage of personal medications. Facility does require this medication to be locked in a safe place within the resident’s personal storage space. The resident is NOT required to disclose to any facility personnel the intent to use the aid-in-dying medication, but the enacted law does require a witness to the resident self-administering this medication. Facility staff will not act as a witness due to reasons of conscience, morality and/or ethics. Facility staff does not witness any verbal or written notices presented to a physician about the desire to obtain and/or use aid-in-dying medications.
59. COUNCILS
Residents have the right to organize and participate in a resident council. (H&S 1569.269(a)(27), 1569.157)
Two or more residents admitted into the facility may form a resident council with the assistance of the facility. The council is composed only of residents, but other may be invited to participate in council meetings. A purpose of the resident council is to make recommendations to the administrator on how to improve the quality of daily living and
promote and protect residents’ rights. Any recommendations presented in writing to the administrator will be acted upon in 14 calendar days or less. The council can meet independently with outside persons or staff, and to be informed of the right to participate in the regulatory inspection process. Other provisions of a resident council are posted in this facility.
Attached as an addendum to this Admission Agreement is our policy on Resident and Family Councils (See Attachments # 5 )
_____ I have received a copy of the Rights of Residents Councils.
When requested by a member of the resident’s family or resident’s representative, facility will allow the formation of a family council and allow the council to meet in the facility during mutually agreed upon hours and in a common meeting room in the facility. A family council is a meeting of family members, friends and others of at least two residents who may confer in private without the presence of facility staff. Facility will assist in the council meeting by posting notices of meetings, and minutes, information or newsletters produced by the council. Facility is unable to write the notices, write the minutes or prepare councilrelated information. Any concerns or recommendations submitted in writing to the administrator by the council will be acted upon within 14 days or less.
60. MOTION DETECTION ALARMS
If the resident gets up throughout the night, it might be a good idea to have a motion censored alarm installed to alert staff that the resident is awake and trying to use the restroom. Mom & Dad’s House supports the use of such items; however, it is the responsibility of the resident’s family to find, purchase and maintain them.
Some of these alarms include:
Floor Alarm Mat - http://www.securesafetysolutions.com/matsets.htm
Chair Alarm
Bed Alarm - Smart Caregiver Wireless and Cordless Weight Sensing Bed Pad – 10” x 30” (Monitor or Alarm Included).
Infrared Motion Sensor - http://smartcaregiver.com/motion-sensor-alarm-systems/
Initial: __________
61. SURVEILLANCE CAMERAS
Facility does not consent to or allow the resident or resident’s representative’s use of hidden or exposed cameras or video equipment, including the concealed or revealed use of recording equipment in resident room or other areas of the facility. It is strictly prohibited under California and Federal privacy laws.
However, facility may use cameras under the following guidance by Department of Social Services:
62. TERMINATION OF SERVICE AGREEMENT
63. MODIFICATION CONDITIONS
Facility may, with a 30-day written notice to resident or responsible person, amend this contract when such an amendment does not involve fees. Resident or responsible person will be asked to sign and date the amendment. In addition, facility will provide resident and/or responsible party with a 30-day written advanced notice of a necessary room change including an emergency or to fill a vacant bed. Resident may agree to waive the 30-day notice and move immediately to a different room.
64. SEVERABILITY
If one provision or paragraph of this agreement shall be invalidated in a legal proceeding, the remaining provisions or paragraphs shall remain in full force and effect.
SIGNATURES
I agree to the terms state in this agreement. Under California Health and Safety Code 1569.887 and Title 22 section 87568(e), the signatures below represents the resident’s or responsible person’s acknowledgement of this agreement’s terms and conditions. I have read and do understand all of the preceding pages. I have received a copy of this agreement and acknowledge that Mom & Dad's House has the original agreement. I agree to all the terms of this agreement.
VOLUNTARY ARBITRATION
Arbitration of Disputes. By signing below, you agree that any and all claims and disputes arising from or related to this Agreement or to your residency, care or services at the Community, whether made against Blue Horizon Homes, LLC d/b/a Mom and Dad's House or it's owners, officers or employees, shall be resolved by submission to neutral, binding arbitration in accordance with the Federal Arbitration Act; except that any claim or dispute involving unlawful detainer proceedings (eviction) or any claims that may be brought in small claims court shall not be subject to arbitration unless both parties agree to arbitrate such proceedings.
Both parties give up their constitutional rights to have any such disputes decided in a court of law before a jury, and instead accept the use of arbitration. The arbitration shall be conducted in the County of Los Angeles, California by a single neutral arbitrator selected as provided for in the California Code of Civil Procedure unless otherwise mutually agreed. In reaching a decision, the arbitrator shall prepare a written decision that includes findings of fact, the reasons underlying the decision, and conclusions of law. Each party shall bear its own costs and fees in connection with the arbitration unless otherwise provided for by statute.
You may withdraw your agreement to arbitrate within thirty (30) days after signing this Agreement by giving written notice of your withdrawal to Blue Horizon Homes, LLC d/b/a Mom and Dad's House .
This arbitration clause binds all parties to this Agreement and their spouses, heirs, representatives, executors, administrators, successors, assigns, managers, and agents as applicable. After termination of this Agreement, this arbitration clause shall remain in effect for the resolution of all claims and disputes that are unresolved as of that date.
In the event that any part of this arbitration clause is determined to be unenforceable, the remaining portions of the clause shall remain valid and shall be enforced by the parties.
By signing below, you warrant that you have had the opportunity to ask questions and have the above paragraphs regarding arbitration of disputes explained to you, that you understand the arbitration agreement's significance, and that you voluntarily agree to be bound by it.
BY SIGNING THIS AGREEMENT THE PARTIES HEREBY WAIVE THEIR RIGHTS TO RESOLVE DISPUTES BY A JURY TRIAL.
ATTACHMENT # 1
LGBT RIGHTS
Health and Safety Code Section 1439.51
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
Explanation: Health and Safety Code Section 1439.51. Each resident shall have LGBT Rights which include, but are not limited to, the following:
1439.51. (a) Except as provided in subdivision (b), it shall be unlawful for a long-term care facility or facility staff to take any of the following actions wholly or partially on the basis of a person’s actual or perceived sexual orientation, gender identity, gender expression, or human immunodeficiency virus (HIV) status:
(1) Deny admission to a long-term care facility, transfer or refuse to transfer a resident within a facility or to another facility, or discharge or evict a resident from a facility.
(2) Deny a request by residents to share a room.
(3) Where rooms are assigned by gender, assigning, reassigning, or refusing to assign a room to a transgender resident other than in accordance with the transgender resident’s gender identity, unless at the transgender resident’s request.
(4) Prohibit a resident from using, or harass a resident who seeks to use or does use, a restroom available to other persons of the same gender identity, regardless of whether the resident is making a gender transition or appears to be gender-nonconforming. Harassment includes, but is not limited to, requiring a resident to show identity documents in order to gain entrance to a restroom available to other persons of the same gender identity.
(5) Willfully and repeatedly fail to use a resident’s preferred name or pronouns after being clearly informed of the preferred name or pronouns.
(6) Deny a resident the right to wear or be dressed in clothing, accessories, or cosmetics that are permitted for any other resident.
(7) Restrict a resident’s right to associate with other residents or with visitors, including the right to consensual sexual relations, unless the restriction is uniformly applied to all residents in a nondiscriminatory manner. This section does not preclude a facility from banning or restricting sexual relations, as long as the ban or restriction is applied uniformly and in a nondiscriminatory manner.
(8) Deny or restrict medical or non-medical care that is appropriate to a resident’s organs and bodily needs, or provide medical or non-medical care in a manner that, to a similarly situated reasonable person, unduly demeans the resident’s dignity or causes avoidable discomfort.
(b) This section shall not apply to the extent that it is incompatible with any professionally reasonable clinical judgment.
ATTACHMENT # 2
Field Trip Release, Waiver of liability and
Hold Harmless Agreement
This Field Trip Release, Waiver of Liability and Hold Harmless Agreement is entered into by or on behalf of _________________________________. From time to time Blue Horizon Homes, Inc (AKA Mom & Dad's House) offers field trips/activities off its premises for its residents. Participation is always voluntary. Public transportation and/ Uber/Lyft are used to transport residents on these Mom & Dad's House sponsored field trips/activities.
By signing this agreement I acknowledge that the mode of transportation and nature of any particular field trip/activity may expose me to increased risks that may result in my illness, personal injury or death and I understand and accept all such risks. In particular, I understand the risk of injury from falls increases during these field trips/activities. I recognize and acknowledge that certain risks of harm are or may be inherent and that Mom & Dad’s House cannot control all risks. I understand that Mom & Dad’s House is not responsible for any medical expenses associated with any property or personal injury that I may sustain on Mom and Dad's House sponsored field trips/activities.
In consideration of Mom & Dad’s House permitting me to participate in field trips/activities outside Mom & Dad's House and in transporting me and/or coordinating transportation, I release Mom & Dad’s House and its officers, employees, and representatives from any and all liability to myself and my personal representatives, estate, heirs, and assigns for any and all claims, demands and causes of action for any and all loss of personal property, illness or injury, including death, arising out of, resulting from, caused by, occurring during or in any way connected with the field trip/activity, including injuries caused by Mom & Dad’s House officers, employees, and representatives, or any other participant in the field trip/activity that I may sustain while participating in such field trip/activity.
I understand that Mom & Dad’s House does not provide medical insurance for me. I am urged by Mom & Dad’s House, to maintain adequate personal health and accident insurance to cover any personal injury to myself which may be sustained while participating in any field trip/ activity.
I agree to indemnify and hold harmless, waive and covenant not to sue Blue Horizon Homes, LLC (AKA. Mom & Dad’s House) officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my own negligent or intentional act or omission while participating in any such field trips/activities. It is my express intent that this Covenant Not to Sue and Agreement to Hold Harmless shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws of the State of California.
ATTACHMENT # 2
Field Trip Release, Waiver of liability and
Hold Harmless Agreement
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND THAT IT IS A RELEASE, WAIVER AND HOLD HARMLESS OF LIABILITY OF ALL CLAIMS FOR ANY INJURY OR DEATH TO MYSELF THAT OCCURS WHILE PARTICIPATING IN ANY MOM & DAD'S HOUSE SPONSORED FIELD TRIP OR OFF PREMISES ACTIVITY AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY OWN NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
I have read and agree to the terms and conditions of the Blue Horizon Homes, LLC. Field Trip Release, Waiver of Liability, and Hold Harmless Agreement. I understand this document will be considered effective on the date signed.
I represent and acknowledge by my signature below that I am fully competent to sign this Agreement. I acknowledge that I am signing this Release, Waiver of Liability and Hold Harmless Agreement on my OWN behalf and I agree to be bound by the terms of this Release, Waiver of Liability and Hold Harmless Agreement.
I acknowledge that I am signing this Release, Waiver of Liability and Hold Harmless Agreement on behalf of _______________________________ as his/her agent and/or legal representative. I agree on his/her behalf to be bound by the terms of this Release, Waiver of Liability and Hold Harmless Agreement. I additionally agree to personally hold Blue Horizon Homes, LLC (AKA. Mom & Dad’s House) harmless for injury to _________________________ resulting from his/her participation in any Mom & Dad's House field trip/activity occurring off the facility premises.
ATTACHMENT # 3
THEFT & LOSS POLICY
THIS THEFT AND LOSS POLICY AND PROCEDURE PROGRAM WILL BE REVIEWED BY ALL STAFF, TWICE A YEAR.
The following paragraphs contain information on the policies and procedures for safeguarding resident’s personal property.
INVENTORY
It is the policy of the facility to maintain a current inventory of all personal property identified by residents. Upon admission, all residents will be requested to appropriately label all clothing and personal items. Residents will be asked to keep no more than $______ cash at any time. Residents will be requested to keep fine jewelry and other items of value in a safe deposit box at their banking institution. No items of value will be entrusted to the facility for safekeeping and no cash or other moneys will be entrusted to the facility. All resident personal items must be inventoried unless the resident refuses the inventory and the refusal is documented. The inventory can be written on the State form or on the form on the following page, if desired. When the form is complete, copies will be distributed to and kept by the facility, the resident’s family or responsible party, and the resident. If the resident has any additions to their personal inventory, it is the facility’s policy to update the list and to make sure that the responsible parties obtain the updated copies. Likewise, when the resident loses or removes any items from their personal inventory, they are to notify the facility immediately and the facility will document appropriately. In the event of a resident’s discharge or a resident’s death, the inventory list will be verified and the personal items will be packed. When the items are returned to the resident’s family or responsible party the list will be re-verified and signed in receipt of belongings.
THEFT AND LOSS
The policy of the facility is to document all theft and loss of personal property. When resident notices a personal item are missing they are to notify the staff immediately. The staff will conduct a thorough search for the missing item or items. If the personal belongings cannot be found, an estimate of their value will be assessed. The estimate will be the original purchase price plus or minus any appreciation or depreciation that has occurred. If the theft exceeds $______ or more, a report shall be filed with a Law Enforcement Agency within 36 hours of the theft. All appropriate documentation of the incident will be given to all the responsible parties. The facility will maintain the records on file for a minimum of three (3) years after the theft. All staff will receive in-service training on the importance of returning resident belongings immediately to the residents’ rooms.
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THEFT & LOSS POLICY
IDENTIFICATION
It is the facility’s policy to label all of the resident’s personal property for their protection. First, all clothing will be labeled with permanent laundry markers to clearly identify which resident they belong to. Second, all personal belongings that can be marked with permanent pen will be marked in discreet locations. In cases where the item or items cannot be safely labeled with a non-erasable marker an electric pencil will be used to engrave the resident’s name in a discreet place on the items, if the resident agrees.
SECURITY
The facility does not have a safe on the premises to allow for safe keeping of residents’ valuables. They are encouraged to use their own private banking institution to provide this service. The facility policy is to provide all rooms with either a lockable door of which the resident has a key or a lockable cabinet of which the resident also has a key.
NOTIFICATION
It is the policy of the facility to notify interested parties about the loss prevention program and provide them with copies of applicable laws. The facility will post the policy and procedures for safeguarding the residents’ property on the information board in the facility. Upon admission to the facility, the resident and interested parties will be notified verbally and given a copy of the Theft and Loss program. Copies of these procedures and applicable laws are available to anyone upon request.
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RIGHTS OF RESIDENT COUNCILS